Marianne Smith

What is the focus of your research? What questions are you trying to answer? What problems are you attempting to solve?

My research focuses on depression among older adults. Depression is a serious public health problem – one that will soon be second only to heart disease in terms of global health burdens. In older adults, loss of pleasure in doing things and feeling sad or blue – the two hallmark symptoms of depression – are too often attributed to age-related problems. This contributes to under-recognition of depression as an illness, and under-treatment of a problem that is often highly responsive to both medication and non-medication therapies. I focus on recognition of depression as an illness, using non-medication interventions to prevent and treat depression symptoms, and involving staff caregivers who often have important roles in restoring well-being.  

I am interested in older adults who live in assisted living where an estimated one in four has clinically meaningful depression symptoms, and average length of residence is short – from two to 36 months. Most people move to assisted living thinking they will live out their lives there, but too often other health problems, like depression, interfere. I am examining three different approaches to depression prevention and treatment in assisted living settings. One uses a computerized cognitive training program that works like a game and has reduced depression symptoms in community-dwelling older adults, but has not yet been evaluated in the generally older and frailer people who live in assisted living settings. Another intervention is a group program that helps elders gain skills to use behavioral activation (increasing pleasant events), exercise, and problem-solving, which are known to reduce risks of developing major depression. The final intervention is providing on-site nursing care management services using a collaborative care model to treat older adults with depression where they live – in their assisted living apartments.

What led to your interest in this topic?

Depression is widely recognized as a leading cause of disability in people of all ages, but is particularly problematic in later life. Depression regularly overlaps with other health problems, including anxiety, pain, cognitive decline, and medical problems, and is highly associated with reduced function and quality of life. The relationship between depression and other problems is often bi-directional (meaning that one can activate the other), and treating both conditions at the same time is often necessary to helping people feel fully well.

The key issue with depression is that it robs people of their quality of life. The dark and depressed mood, feelings of helplessness and hopelessness, that nothing is fun anymore (anhedonia), or that life isn’t worth living (suicidal thoughts) are all part of depression. Depression also causes physical symptoms, like feeling tired all the time, having no appetite, not being able to sleep, and feeling slowed down physically. Often, many older people blame their physical health problems or age-related losses for the symptoms, but in reality, depression is the culprit. The downward cycle of depression – of feeling bad, doing less, and then feeling worse – is both treatable and preventable. We have to recognize depression as a serious medical illness, not just a passing mood or an “understandable consequence” of age-related problems, in order to help people back to wellness.

What impact (on citizens, practice environment, educational opportunities, funding, etc.) do you predict will come from this research?

The disability associated with depression can have devastating consequences for older people and society at large. For example, we know that health care costs are higher in every category for elders with depression compared to those aren’t depressed. And we can’t begin to put a price tag on the emotional and physical suffering that the older person, and often their family, endures as a result of depression. The worse they feel physically and emotionally from the depression, the less likely they are to engage in usual self-care routines. That includes taking medications to treat their other health problems, staying physically active which is good for both their mood and overall physical function, and doing enjoyable and meaningful activities that are known to buffer depression.  

As they do less, the risk of declining health and function increases, as does the risk of losing their independence and autonomy. In other words, depression-related health problems may result in loss of function and disability that demands more assistance with personal care routines, medication management, and managing other health-related problems. In turn, the older person may need to relocate to a setting where their care needs can be met. For older people residing in assisted living settings, that often means being relocated to nursing home care, which is more restrictive and often more costly than living in an apartment with services. If depression is properly diagnosed and treated, the opportunity to promote self-care increases – allowing older people to live where they want and to enjoy better all-around quality of life. (This also reduces health care costs related to undiagnosed or under-treated depression.)

How does the research integrate into education/practice/service?

Because depression is the most common psychiatric illness among people of all ages, the topic is relevant to everyone – from the staff who provide daily care in assisted living, to family members and friends, and of course older adults themselves. The approach I use in my depression research is collaborative and community focused. I don’t think we can effectively identify, prevent and treat depression among older adults who live in assisted living without also engaging the larger “community” in which that person lives; therefore, in my research, staff education about depression and depression-related interventions is a key component. And part of that education is learning how to recognize depression; how to talk about it openly; and how to educate the elder and his or her family. The nurse manager becomes a “key contact” who supports staff and interacts with family members and the elder’s primary care provider. Strategies to support and extend interventions used – whether that is the computer game or group meetings or nurse care management services – are always a part of the program. The goal is to help the individuals who provide daily care gain skills that will help them long after the research study is over.

For example, in my recent feasibility study I educated the nurse manager and selected staff about depression and how to use a widely accepted rating scale to quantify symptoms. We talked about what the scores meant, and how to use them to talk to physicians and families. The nurses later all reported that they are now using the scale as part of their routine admission assessment so they are sure to pick up depression early (even though that wasn’t something I asked them to do). One nurse in particular also told me about how she was able to use the tools discussed during the staff training program to identify and approach a resident she suspected was depressed. The nurse was delighted to find that the elder wasn’t offended or put off by the discussion, and in fact was relieved to talk about it openly.

That’s the kind of story that makes it all worthwhile.